Are accident and emergency attendances increasing?

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Pressures on accident and emergency (A&E) departments hit the headlines last week, with the Prime Minister and Leader of the Opposition trading statistics across the despatch box at Prime Minister’s Question Time. But what are the facts about A&E attendances?

Figure 1 shows trends in attendances in English NHS A&E units over the past 26 years. The topline trend shows that for 15 years – from 1987/8 to 2002/3 – attendances were essentially unchanged at around 14 million per year. But in 2003/4 they jumped – by nearly 18 per cent – to 16.5 million, and rose to 21.7 million by 2012/13. This is an overall rise of around 7.5 million (a 50 per cent increase) over the past decade.

Figure 1: Annual attendances in English A&E units: 1987/8 to 2012/13

Annual attendances in English A&E units: 1987/8 to 2012/13

Data source: Department of Health, Total time spent in accident and emergency (pre-2011/12 Q2) and NHS England, A&E waiting times and activity (current)

While the Secretary of State for Health, Jeremy Hunt, has suggested that changes to the GP contract around 2004 are to blame for the rise in A&E activity, the facts about accident and emergency workload statistics are not straightforward.

As Figure 1 also shows, in 2003/4 – when the large increase in attendances started – there was a change in the data series. Until 2003/4, statistics on A&E attendances included ‘major’ A&E units only. But around this time more, smaller units – including walk-in centres (WiCs) and minor injuries units (MIUs) – were introduced with the intention of diverting less serious emergency cases away from the larger, more expensive A&E departments, and the statistical collection was changed to record attendances separately for ‘type 1, 2 and 3’ units. Type 1 essentially reflecting major A&E units and types 2 and 3 defined as the smaller, walk-in and minor injuries units, together with specialist emergency departments.

So, much of the increase in 2003/4 was due to previously unrecorded attendances now being collected, but also additional – but less serious – work being carried out in the new units. From 2003/4 to 2012/13, attendances in type 1 units have remained more or less unchanged. It is attendances in type 2 and 3 units that account for all the increase.

While the NHS has experienced a phenomenal increase in accident and emergency workload over the past decade, over the past 30 months this increase has started to level off. Figure 2, for example, shows weekly attendances between November 2010 and April 2013 together with a trend line. The trend increase over the whole period is around 3.5 per cent – about 1.3 per cent per year.

Figure 2: Weekly attendances in A&E units: November 2010 to April 2013

Weekly attendances in A&E units: November 2010 to April 2013

Data source: NHS England, Weekly SitReps, 2013-14

Over the past decade there has certainly been a huge increase in work. But this is partly attributable to the changes in statistical collection and a degree of ‘supply induced demand’ as new routes into emergency care (WiCs, MIUs) opened. In addition, the possible substitution of some types of care (a visit to the GP) by others (a visit to a minor injuries unit) may have increased A&E attendance statistics, but given that WiCs and MIUs are generally not open out-of-hours, it is not easy to see how the rising workload of these services is linked to changes in GP out-of-hours arrangements, as implied by the Secretary of State for Health.

The increase in A&E workload has slowed in recent years, so the question now is not so much how to slow the speed of the increase, but how close to capacity the system is. The recent figures showing that the target that 95 per cent of patients should not wait longer than four hours in A&E is being breached on an increasingly regular basis is indicative of capacity problems amongst other things. Slowly raising the temperature does eventually boil the frog.

Comments

sean boyle

Comment date
30 April 2013
Looks to me like planned follow-up attendances were included at least pre-2003-04 but excluded at least from 2011-12 on. certainly the 16.5 million in 2003-04 includes planned follow-up. so the changes in data definition are causing even more problems. if I am right, then A&E attendances have probably gone up more in the later years than you indicate, but I do not have a figure for total follow-ups, nor breakdown between planned and unplanned follow-ups.
ps i think the word verification is a little inappropriate.

Mark Easton

Comment date
02 May 2013
A very interesting article. Aren't there two issues it doesn't address though?

1. Haven't GP attendances gone up substantially over this period? So WICs and the rest not only have not reduced type 1 A&E activity, they haven’t substituted for primary care consultations

2. Don’t some A&E departments have within them type 2 units? Not all type 2 units are off site, so total A&E activity has continued to go up and type 1 activity has not gone up as planned, indeed from the graph it appears to continue to rise.

Joe Farrington…

Organisation
British Red Cross
Comment date
02 May 2013
I think you used the word admission rather than attendance in para 5. An important difference which is sometimes lost in debate about GP access, so-called inappropriate attendances and the much bigger issue of changes in acute need.

In terms of waiting times and heat in waiting rooms/ A&E itself, attendances are important, but in terms of overall heat in acute system, pressure on beds and overall costs, admissions and bed days are surely the important issue rather than attendances.

I know KF has done lots on this too.

Harry Longman

Position
Chief Executive,
Organisation
Patient Access Ltd
Comment date
02 May 2013
Thank you for clarifying. To Mark's point, GP consults have gone up too so no substitution for WIC activity there, but have the WICs taken some of the demand which would have gone to A&E and therefore helped? Your data suggests not. Why would the previous decade trend not have continued with very slow growth? If so, we have shown supply induced demand once again, or as the saying goes, "Build it, and the people will come."

Michael Crawford

Comment date
02 May 2013
If anyone doubts that market models do not apply well to the NHS, the notion that “supply led demand” is a bad thing should convince them. The commercial world employs a sales force precisely for the purpose of increasing demand to consume the available supply.

In the world of the NHS we have the problem of inequality of access to healthcare; for example people from a deprived locality are less likely to receive a timely diagnosis of cancer or to have a joint replaced. The emergency department, of whatever type, represents a facility where they can compete on an even playing field so an increase in supply for them is a good thing. So perhaps John Appleby is showing us an example of temporarily easing the problem of supply-limited demand.

John Appleby

Position
Chief Economist,
Organisation
The King's Fund
Comment date
02 May 2013
Thanks for these comments. Here are some responses:

Sean: yes, possible problem re 'planned cases'...but we are reasonably assured by DH stats people that none of the 'subsequent' attendance data in either graph includes planned subsequent attendances. We have trawled through guidance docs as far as possible and these seem to confirm this.
Mark: Yes, GP attendances up as far as I know. Maybe they would have gone up even more without WiCs and MIUs? Not quite clear on your second point.
Joe: Yes, 'admissions' a typo - should be attendances. Will be corrected. Regarding where the 'real' problem in secondary care is, well yes, but we are writing about A&E here (which is still an important part of the acute system)!
Harry/Michael: On the 'supply induced demand' point, not all SID is bad of course. What we might have here is unmet demand at last being met through WiCs etc. Which is not necessarily a bad thing (though could argue if NHS treating things that people could deal with themselves is a good use of scarce resources, for eg). Equally, btw, SID by private sector also not necessarily a bad thing in health care or in other sectors; my demand for ipods was 'induced' by Apple's supply of the things - that's fine by me!

John Appleby

Position
Chief Econoist,
Organisation
The King's Fund
Comment date
02 May 2013
...Sorry, Sean, should have clarified that the 'subsequent attendance' data is rolled up into the 'total attendance' figures we use in the charts. The other bigger chunk of attendances are 'first' attendances.

Andrew Dicker

Position
GP,
Organisation
Millbank Medical Centre
Comment date
02 May 2013
Where is the problem? Public use of walk-in centres, urgent care centres, A&E etc reflects public approval of the availability of these services. No one goes to them without careful consideration first because the needs of the users are complex. The paternalistic condemnation of the public for using services 'inappropriately' is absurd and unethical. The services which the public vote for with their feet should be properly resourced and functional.

pkerr

Position
ED Cons,
Organisation
NHS
Comment date
04 May 2013
The argument that level 2 and 3 units account for the increase is surely overly simplistic? there was always small units and around this time remember widespread reconfiguation was occurring with many units merging leading to the downgrading of many.
The problem surrounding ED use has much more to do with the failure to manage unscheduled care in the community and GP referrals increasing, during a period of drastic cuts in bed numbers.
There is evidence that many of the ambulatory patients who should not need admission end up being admitted just because its not possible to get them home once they arrive in ED.
If we can't find ways to manage non emergency unscheduled/acute problems in the elderly population without ED referral for assessment as the default option, then further detioration is unavoidable

john kapp

Comment date
06 May 2013
I note that there is a peak of about 5% higher than average each month probably correspending with the full moon, which indicates an astrological disturbance to our emotions when the sun and moon are in opposition

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